| NPI | 1043608433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 10063) |
| Additional Taxonomies | 103TH0004X Psychologist Health (Licence: MA 10063) |
| Enumeration Date | 2015-01-07 |
| Last Update Date | 2015-01-07 |